<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208244
Report Date: 05/31/2022
Date Signed: 05/31/2022 09:41:29 AM


Document Has Been Signed on 05/31/2022 09:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:MY CARE HOMEFACILITY NUMBER:
107208244
ADMINISTRATOR:PONDOC, GLENDAFACILITY TYPE:
740
ADDRESS:5618 N TRACY AVETELEPHONE:
(559) 305-1682
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 0DATE:
05/31/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Glenda PandocTIME COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Katie Brown arrived at the facility as scheduled to conduct the Case Management visit regarding facility closure. LPA met with Administrator (AD) Glenda Pandoc.

LPA toured the facility inside and out with AD. LPA has confirmed there are no residents at the facility or in care.

AD forfeited and provided the facility license to the LPA during the visit.





A copy of this report was provided via email to dangle76@yahoo.oom and an exit interview conducted with Glenda Pandoc.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1